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Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa

INTRODUCTION: International calls for universal health coverage (UHC) have led many countries to implement health sector reforms, however, since the 2008 global recession, economic growth has slowed in many lower-income and middle-income countries. In a renewed interest in public financial managemen...

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Autores principales: Wishnia, Jodi, Goudge, Jane
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7597483/
https://www.ncbi.nlm.nih.gov/pubmed/33122297
http://dx.doi.org/10.1136/bmjgh-2020-003524
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author Wishnia, Jodi
Goudge, Jane
author_facet Wishnia, Jodi
Goudge, Jane
author_sort Wishnia, Jodi
collection PubMed
description INTRODUCTION: International calls for universal health coverage (UHC) have led many countries to implement health sector reforms, however, since the 2008 global recession, economic growth has slowed in many lower-income and middle-income countries. In a renewed interest in public financial management (PFM), international organisations have emphasised the importance of giving spending control to those responsible for healthcare. However, centralisation is a common response when there is a need to cut expenditure due to a reduced budget; yet failure to decentralise often hampers the achievement of important goals. This paper examines the effect of centralising financial decision-making on the functioning of the South African health system. METHODS: We used a case study design with an ethnographic approach. Primary data collection was conducted through participant-observation and semistructured interviews, over 1 year. Member checking was conducted. RESULTS: New management implemented centralisation due to a reduced budget, a history of financial mismanagement, the punitive regulatory environment financial managers face, and their fear of poor audit outcomes. The reform, together with an authoritarian management style to ensure compliance, created a large power distance between financial and clinical managers. District managers felt that there was poor communication about the reform and that decision-making was opaque. This lowered commitment to the reform, even for those who thought it was necessary. It also reduced communal action, creating an individualistic environment. The authoritarian management style, and the impact of centralisation on service delivery, negatively affected planning and decision making, impairing organisational functioning. CONCLUSION: As public health systems become even more financially constrained, recognising how PFM reforms can influence organisational culture, and how the negative effects can be mitigated, is of international importance. We highlight the importance of a participatory culture that encourages shared decision making and coproduction, particularly as countries grapple with how to achieve UHC with limited funds.
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spelling pubmed-75974832020-11-05 Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa Wishnia, Jodi Goudge, Jane BMJ Glob Health Original Research INTRODUCTION: International calls for universal health coverage (UHC) have led many countries to implement health sector reforms, however, since the 2008 global recession, economic growth has slowed in many lower-income and middle-income countries. In a renewed interest in public financial management (PFM), international organisations have emphasised the importance of giving spending control to those responsible for healthcare. However, centralisation is a common response when there is a need to cut expenditure due to a reduced budget; yet failure to decentralise often hampers the achievement of important goals. This paper examines the effect of centralising financial decision-making on the functioning of the South African health system. METHODS: We used a case study design with an ethnographic approach. Primary data collection was conducted through participant-observation and semistructured interviews, over 1 year. Member checking was conducted. RESULTS: New management implemented centralisation due to a reduced budget, a history of financial mismanagement, the punitive regulatory environment financial managers face, and their fear of poor audit outcomes. The reform, together with an authoritarian management style to ensure compliance, created a large power distance between financial and clinical managers. District managers felt that there was poor communication about the reform and that decision-making was opaque. This lowered commitment to the reform, even for those who thought it was necessary. It also reduced communal action, creating an individualistic environment. The authoritarian management style, and the impact of centralisation on service delivery, negatively affected planning and decision making, impairing organisational functioning. CONCLUSION: As public health systems become even more financially constrained, recognising how PFM reforms can influence organisational culture, and how the negative effects can be mitigated, is of international importance. We highlight the importance of a participatory culture that encourages shared decision making and coproduction, particularly as countries grapple with how to achieve UHC with limited funds. BMJ Publishing Group 2020-10-29 /pmc/articles/PMC7597483/ /pubmed/33122297 http://dx.doi.org/10.1136/bmjgh-2020-003524 Text en © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
spellingShingle Original Research
Wishnia, Jodi
Goudge, Jane
Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa
title Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa
title_full Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa
title_fullStr Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa
title_full_unstemmed Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa
title_short Impact of financial management centralisation in a health system under austerity: a qualitative study from South Africa
title_sort impact of financial management centralisation in a health system under austerity: a qualitative study from south africa
topic Original Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7597483/
https://www.ncbi.nlm.nih.gov/pubmed/33122297
http://dx.doi.org/10.1136/bmjgh-2020-003524
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